Provider Demographics
NPI:1306476734
Name:JUAREZ, DESERAY JOYCELIN R
Entity type:Individual
Prefix:MISS
First Name:DESERAY
Middle Name:JOYCELIN R
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 WESTHOLME WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4832
Mailing Address - Country:US
Mailing Address - Phone:916-410-2449
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678
Practice Address - Country:US
Practice Address - Phone:916-410-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXDJ90008931DMedicaid